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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 52, Num. 4, 2004, pp. 522-523

Neurology India, Vol. 52, No. 4, October-December, 2004, pp. 522-523

Letter To Editor

Fulminant subdural empyema-an unusual complication of pyogenic meningitis

Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal - 576 119, Udupi, Karnataka
Correspondence Address:Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal - 576 119, Udupi, Karnataka,

Code Number: ni04185


An otherwise normal 56-year-old diabetic patient presented with a one-day history of multiple generalized tonic-clonic seizures followed by altered sensorium. There was no history of fever. There was no history of trauma or any focus of infection. There was no focal neurological deficit or signs of meningitis.

Hematological investigation revealed leucocytosis with a total white blood cell count of 16,600/ and an ESR of 45 mm. Blood sugar was 351 mg%. Computed tomography (CT) scan of the brain revealed no abnormality [Figure - 1]. The lumbar CSF analysis revealed 1350 cells/mm with 96% neutrophils and 04% lymphocytes. Blood and CSF cultures did not reveal any growth. A diagnosis of pyogenic meningitis with diabetes was considered and the patient was placed on broad-spectrum antibiotics. Two days after admission to the hospital she developed recurrent attacks of seizures, lapsed into altered sensorium and developed a left pupillary dilatation. Repeat CT scan revealed a left fronto-parietal hypodense, extracerebral fluid collection with severe brain edema causing midline shift and obliteration of the basal cistern [Figure - 2]. An emergency left frontal burr hole was done and thick pus was evacuated. Gram′s stain revealed pus cells and gram-negative bacteria and the culture showed growth of Klebsiella species. The patient deteriorated rapidly and died.

Subdural empyema complicating meningitis is relatively common in infants, but is rare in adults.[1],[3] Our experience in the present case suggests that subdural empyema should be suspected in patients with pyogenic meningitis who develop recurrent seizures, focal neurological deficit or deteriorate neurologically.[3],[4],[5]


1.Nathoo N, Nadvi SS, vanDellen JR, Gouws E. Intracranial subdural empyemas in the era of computed tomography: A review of 699 cases. Neurosurgery 1999;44:529-36.  Back to cited text no. 1    
2.Pfister HW, Feiden W, Einhaupl KM. Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study. Arch Neurol 1993;50:575-81.  Back to cited text no. 2  [PUBMED]  
3.Pathak A, Sharma BS, Mathuriya SN, Khosla VK, Khandelwal N, Kak VK. Controversies in the management of subdural empyema. A study of 41 cases with review of literature. (Wien) Acta Neurochir 1990;102:25-32.  Back to cited text no. 3  [PUBMED]  
4.Ogilvy CS, Chapman PH, McGrail K. Subdural empyema complicating bacterial meningitis in a child: Enhancement of membranes with gadolinium on magnetic resonance imaging in a patient without enhancement on computed tomography. Surg Neurol 1992;37:138-41.  Back to cited text no. 4  [PUBMED]  
5.Mahapatra AK, Pawar SJ, Sharma RR. Intracranial salmonella infections: Meningitis, subdural collections and brain abscess. A series of six surgically managed cases with follow-up results. Pediatr Neurosurg 2002;36:8-13.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

Copyright 2004 - Neurology India

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